ASHM Report Back

Clinical posts from members and guests of the Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM) from various international medical and scientific conferences on HIV, AIDS, viral hepatitis, and sexual health.

A point that struck me as important and should be given great consideration when managing patient’s HIV treatment is that they be given all available treatment options and that their choice should come first before a practitioner’s favourable choice of treatment. This given enhances treatment compliance which could spell success or failure of therapy. The patients are the masters of their bodies and therefore the best source of information as to effectivity of treatment for medications affect everyone differently. Medication’s efficacy is not measured by the number of pills taken.

When a patient contemplates and opens about wanting to change their medication, these should be given appropriate consideration; alternative medications be discussed freely and effects both positive and negative be laid out. Viral load testing is not necessary in all cases unless the medication change is due to drug resistance.

The Talk was by Rimke Bijker who is a PhD Student from The Kirby Institute.

As aging population with HIV positive in Asian countries, risk of increasing trend of Cardiovascular Disease is unavoidable. Overtime, about 60 % of patients (HIV Positive) will be aged over 40 years in 2025.

Risk of Cardiovascular Disease (CVD)comprises traditional risk factors as well as specific factors

There has been a large shift in the practice of HIV medicine towards that of chronic disease management and management of co-morbidities. One such co-morbidity is osteoporosis/osteopenia – the incidence of which is increasing, driven in part by the ageing HIV population, as well as ART-related effects such as tenofovir disoproxil fumurate (TDF) use. In the session on ‘Trials, Treatment and Toxicity’, Prof Jenny Hoy from the Alfred Hospital and Monash University discussed her findings on a recently completed randomized trial looking at the bisphosphonate zoledronic acid versus TDF-switching on bone mineral density (BMD). Main points from the talk:

-TDF has previously been shown to cause lower BMD and increases fracture risk (TAF has been shown to have less of an effect on BMD than TDF)

-Switching from TDF to another agent shows improvement in BMD

-Zoledronic acid has also previously been shown to increase BMD vs placebo in HIV-positive individuals

-The trial was a randomized, open-label 2-year trial testing zoledronic acid (5mg) vs switch of TDF to alternate ARV (in most cases to abacavir or an integrase inhibitor) on BMD at time 12 months and 24 months

-43 patients were analysed for the zoledronic acid group and 42 for TDF-switching

-There was significantly higher increase in BMD in the zoledronic acid group compared to the TDF-switching group (6.1% vs 2.9%) at 12 months, which continued to increase in the zoledronic acid group at 24 months (7.4% vs 2.9%)

-The study was not powered to comment on changes in fracture rates

Overall the study demonstrated significant increases in BMD in patients treated with zoledronic acid compared to TDF-switching, however it remains to be seen whether this translates clinically to reduced rates of fractures. Given the ageing cohort of the HIV population and predicted increase in osteopenia/osteoporosis, coupled with previous data demonstrating increasing frailty – risk of fractures remains an important clinical concern. Clinicians should aim to screen for and manage risk factors for co-morbidities early. This was summed up in Prof Georg Behrens opening plenary talk– to consider a ‘hit hard and early’ approach to HIV co-morbidities.

The final information station on this Italian inspired food for thought train was a digestive Espresso of Epidemiology “Understanding our evolving epidemic”.

First up was HIV and Ageing – Rosan van Zoest (PhD student at the Amsterdam Institute for Global Health and Development) used cohort data from large studies to separate the Myths from Reality. The opener of the talk was a review of all the suggested AANCC’s (age-associated non-communicable comorbidities). The following speech-bubbles were presented for unpacking “HIV causes accelerated ageing”, “Ongoing inflammation is the cause of comorbidities”, “Comorbidities are due to antiretroviral toxicity”, “AANCC’s occur more often in PLHIV” and “HIV causes premature ageing”. Data from the COBRA, POPPY and AGEHIV studies were used to respond to the statements and one of the key factors strengthening the evidence was the importance of recruitment of appropriate HIV-negative controls and reference was given to the COBRA study that used HIV- and age matched blood bank donors as a comparison. After reviewing the evidence, Rosen concluded when reviewing evidence one should be careful not compare ‘apples and oranges’, control groups are vital, AANCC’s are more prevalent in PLHIV, comorbidity risk in PLHIV is likely multifactorial and when considering the above speech-bubbles the following should be considered; smoking, drug and alcohol use, CVD risk and DM, weight related conditions such as obesity and anorexia, HCV, systemic and intrathecal immune activation, certain ARVs and nadir CD4.

As Milan is one of the fashion capitals of the world it seemed appropriate at some point that we talk about Modelling… kind of… Supporting the development of evidence based police/management guidelines was presented by Mikaela Smitt from Imperial College London. This session was focussed on the “black box” of modelling studies and for those that can comprehend this analogy she used a picture of big yellow minion and thought bubble “WHAAA?!?!?!” as the opening slide…a sentiment I am familiar when trying to get my head around modelling. Needless to say, she unravelled it brilliantly.

What is modelling and what does it do? It predicts the future, compares interventions, uses epidemiological mechanisms, uses fundamental parameters and suggests resource allocation.

What is good model practice? A new acronym was given to use here (and a picture of the popular Harry Potter Hogwarts popular sport) QUEDDACH. The QUESTION is concise and specific including outcomes, measures, settings and timelines. The DESIGN includes what key elements and interactions are represented. The DATA is underpinned by key/strong data sources. The ASSUMPTIONS should be defined as well as what impact they have on the results. The CHECKS and sensitivity/uncertainty analyses should be done.

And finally what are the potential problems with modelling data? Wrong tool is used for the job, garbage in = garbage out, Complex questions = greater uncertainty

And so for my final blog of Mind stimulating Mozzarella… (Sorry am running out of cheesy puns.. whoops and again!)

“What is happening with new HIV diagnoses in gay men in England and why? Interpreting monitoring (outputs) and surveillance (outcomes) information” presented by Professor Noel Gill from Public Health England. Noel started by commenting on England as a high-income setting, the open access network of 200 STI clinics held in high regard by at risk community and excellent surveillance and monitoring systems. He posed the temporal changes from 2010 onwards noting the HIV complacency with increasing survival and better ARV regimens, problematic increasing density of sexual networking driven by the arrival of geospatial hook-up smartphone apps and a marked increase in bacterial STI’s. Trends in common STI diagnoses were examined as well as reviewing some of the policy developments affecting them such as behavioural interventions, lower thresholds of access to HIV testing (e.g. the Dean St 1hr promise, self-sampling and Self-testing), Increases in HIV testing frequency following recommendations of 3 monthly testing for those having condomless AI with new or casual partners and HIV PrEP (PROUD trial commencing in 2013).

Noel concluded with the following information on Preventing HIV in MSM. Combination prevention has seen a 50% increase in MSM clinic attendees from 2011 – 2016, intensified testing of those at risk has seen an average of 2.5 test annually in 2016 and suggested the question clinicians should be asking is “How frequently are you testing, not when did you last test”. Shortening the time to treatment initiation in PLWHIV and HIV PrEP has all had a significant contribution. Noel closed by highlighting the commencement of the IMPACT study a pragmatic health technology assessment of PrEP and its implementation that aims to answer the key questions under real world conditions and at sufficient scale. The results will inform service commissioners on how to support clinical and cost-effective PrEP access in the future.

Thank you to ASHM for your generous scholarship funding for myself and the other Australian sexual health clinicians who benefited from this – we had a blast! Ciao x

Day 3 at #EACS2017 and my neurone nourishment started with an Antipasto of "Abstract Writing" by Caroline Sabin (Professor of Medical Statistics and Epidemiology at University College London (UCL)). This was an early morning session and the smaller audience lent itself well to an interactive tutorial style where we were asked to critique a ‘poorly written abstract’. Here are the bite-sized “do’s and don’ts”.

TITLE – Should be short and snappy. DO NOT inaccurately represent the project. Questions are often great to pose in a title.

INTRO – V. brief! One sentence to describe the problem and one to describe the research. Hook the reader here by this point the reader should know what you are going to do.

RESULTS – DO mention brief demographics of sample, this section should be numbers rich, confidence intervals and comparative statistics. DO NOT discuss interpretations here.

CONCLUSIONS – DO NOT repeat results (keep it brief). DO aim for one or two statements – How will this help? What is the future? Any major limitations?

Having reviewed many of the abstracts for EACS Caroline’s feeling is that the abstracts tell the reviewer as much about you as it does about your research. With this in mind her final tips included ensuring correct English language and grammar, is this the right conference for you?, no need for references, use ‘dashes’ effectively they will help your word count, be careful with bold and italics it does not always translate, a little tip …if you must use a table JPEG images often only use one character, avoid jargon. Finally she commented that abstracts that did not get accepted are largely due to lack of clarity on the project, inappropriate for the conference, poor study design, no sample size mentioned, no bias acknowledged, no clinical value.

Next up for something to chew on was the first plenary Eradication of Hepatitis C in HIV coinfection presented by Andri Rauch (Associate professor of infectious diseases, University Hospital Bern, Switzerland). Andri reminded us of the WHO goals of Hepatitis C management. He discussed the higher the HCV prevalence, the more treatment is needed to achieve elimination. Scaling up harm reduction reduces the required treatment rates. He demonstrated a colourful “spaghetti junction” of graphical information showing clusters of behaviours and phylogenetic analysis of international transmission networks to show areas where trends of information can be used to improve counselling and behavioural interventions and where targets for disruption of transmission needs to occur to aim for elimination. Focusing on Europe he showed data which demonstrated the hurdles to HCV elimination in Europe which are largely around access to therapy, affordability and reimbursement restrictions. The proportion of re-infections increases with treatment upscale but overall incidence and prevalence decrease if risk behaviour stabilises. Fear of re-infections is NOT an argument against treatment upscale. In conclusion he stated the central elements of HCV elimination include 1) Optimized screening and diagnosis strategies, 2) Optimized prevention and risk counselling, 3) Increased treatment uptake and access to IFN-free DAA for all at affordable prices, 4) Coordinated national and international HCV strategies and leadership.